complaint·July 9, 2025

It was alleged that R1 refused care from a staff, the staff brought another staff and forced care on R1, and R1 fought back and was injured with a skin tear as a result. LPA inspected the facility, conducted health and safety checks on residents, and observed that R1 has three small scabs on their left arm and a very large hand-shaped bruise on their right arm. Per R1’s Physician’s Report dated January 16, 2025, R1 has mild cognitive impairment but R1’s Medical Records indicate that R1 was diagnosed with dementia with behavioral disturbances on July 2, 2025. LPA interviewed R1 who was aware they were injured, but was unable to provide information regarding how the injuries were sustained due to R1’s dementia diagnosis and LPA noted R1 to be confused and easily agitated. LPA interviewed RCD who stated that on June 24, 2025, Staff #1 (S1) noted that R1, who lived in assisted living at the time, was very soiled and tried to provide care to R1, R1 refused, S1 brought Staff #2 (S2) to help, R1 resisted and attacked S1 and S2, and S1 and S2 completed care for R1 but R1 sustained a skin tear during the incident. LPA reviewed the facility’s investigation report dated July 8, 2025, which indicates that R1’s family had noted a recent cognitive decline in R1 prior to the incident and that shortly after the incident on June 24, 2025, R1 was medically reassessed with a diagnosis of dementia and admitted to the memory care unit. AD stated that after the incident, staff were retrained on resident refusals, providing care, and personal rights. LPA reviewed the staff files for S1 and S2 and confirmed they are both background cleared and have up to date training. LPA attempted to interview S1 and S2, but they were not available for interview. However, their statements are incorporated into the facility’s investigation report dated July 8, 2025 and LPA’s observations confirmed R1’s injuries. RCD stated that S1 and S2 did not follow facility protocol when they forced care on R1 and that they should have waited, given R1 time, called the family, called managers, and taken other measures to prevent the incident as it occurred. LPA reviewed R1’s Care Notes which indicate that R1 was observed to be very confused, not making any sense, and being rude and aggressive with staff and other residents since late February 2025, but R1 was allowed to stay in assisted living until the incident on June 24, 2025. Based on the information obtained, S1 and S2 forced care on R1, an assisted living resident who likely should have been in memory care, resulting in skin tears as well as a very large bruise on R1’s arm indicating that R1 was held very firmly during this incident. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. This is an amended report